Uptake of appointment spacing model of care and associated factors among stable adult HIV clients on antiretroviral treatment Northwest Ethiopia

Introduction Ethiopia launched an Appointment Spacing Model in 2017, which involved a six-month clinical visit and medication refill cycle. This study aimed to assess the uptake of the Appointment Spacing Model of care and associated factors among stable adult HIV clients on ART in Ethiopia. Methods A cross-sectional study was conducted from October 3 to November 30, 2020 among 415 stable adult ART clients. EpiData version 4.2 was used for data entry and SPSS version 25 was used for cleaning and analysis. A multivariable logistic regression model was fitted to identify associated factors, with CI at 95% with AOR being reported to show the strength of association. Results The uptake of the appointment spacing model was 50.1%. Residence [AOR: 2.33 (95% CI: 1.27, 4.26)], monthly income [AOR: 2.65 (95% CI: 1.13, 6.24)], social support [AOR: 2.21 (95% CI: 1.03, 4.71)], duration on ART [AOR: 2.41 (95% CI: 1.48, 3.92)], baseline regimen change [AOR: 2.20 (95% CI: 1.02, 4.78)], viral load [AOR: 2.80 (95% CI: 1.06, 7.35)], and alcohol abstinence [AOR: 2.02 (95% CI: 1.21, 3.37)] were statistically significant. Conclusions The uptake of the ASM was low. Behavioral change communication, engaging income-generating activities, and facility-level service providers’ training may improve the uptake.

Introduction region [23]. Currently, thirty-nine public health facilities; ten hospitals, and twenty-nine health centers provide ART services in the zone. During the study period, more than eighteen thousand people were living with HIV and all ART rendering facilities were providing ASM services in the study area [23]. Among these ART sites, three hospitals, and nine Health Centers were high caseload ART facilities that hosted more than 500 cases selected for this study in the Zone [23,24]. Stable adult clients on ART were considered as a source population and patients accessing care in high caseload ART health facilities were potentially included in the study (Fig 1).

Sample size determination and sampling procedures
The sample size was determined using a single population proportion formula by considering 50% proportion as there is no previous evidence on uptake of ASM, 5% level of precision, 95% confidence level (CI), and 10% non-response rate yielding a final sample of 423. Based on this sample calculation, all study participants were selected from high caseload ART facilities through proportional allocation to each facility based on their respective patient loads during the study period. Finally, each study participant was selected using a systematic random sampling technique of the "K" interval for every 3 rd patient.

Definition of variables
Uptake of ASM. Eligible ART clients who fulfill the World Health Organization's (WHO) criteria of stable adult clients accepting the six months schedule for both clinical evaluation and medication refill were categorized as 'uptake' and coded as "1" whereas those who refused to be enrolled in ASM were categorized as 'non-uptake' and coded as "0" [6]. Stable adult clients. Patients who are on ART and meeting the following criteria were considered stable: at least one year, aged �18 years old, no adverse drug reactions requiring regular monitoring, a good understanding of lifelong adherence, have two consecutive viral loads <1000 copies/ml or CD4 counts above 200 cells/mm 3 , no acute opportunistic infections, and not pregnant or breastfeeding [5].
Alcohol use. Patients were scored on the Cut down, Annoyed, Guilty, and Eye-opener (CAGE) Substance Abuse Screening Tool which was scored 0 for "no" and 1 for "yes" answers, with a higher score being an indication of alcohol problems. A total score of �2 is considered clinically significant [17].
Adherence to HIV chronic care principles. A tool on chronic care assessment of the 5As (assess, advise, agree, assist, and arrange) was used. Responses were scored ranging from 5-20. A summed score greater than the mean value is considered "acceptable care", otherwise the individual was assessed as "not acceptable care" [18].
ART-related knowledge. Each respondent's knowledge about ART (6 items) was scored and summed. One point was given for each question that was answered correctly. Participants' level of knowledge was treated as good if they scored correctly on more than half of the ARTrelated knowledge questions [20].

Data collection tools, procedures, and quality assurance
The data collection tool was prepared in English and then translated into Amharic. All data were translated to English to maintain consistency and coherence for analysis. Data were collected using exit interviews supported with individual chart review techniques. The tools were prepared after reviewing prior research as well as the Ethiopian ART intake and follow-up forms [5,7,10,[17][18][19][20][21][22]. Twelve nurse data collectors and four public health professional supervises participated. To ensure data quality, training was given to both data collectors and supervisors. Close supervision was maintained during the entire data collection period. All filled questionnaires were checked for completeness, clarity, and consistency. Any missed or unfilled data was corrected immediately during the data collection period. Finally, all collected data were reviewed and checked for completeness before data entry.

Data processing and analysis
Collected data were coded and entered using EpiData Version 4.2 and exported to SPSS Version 25 software for data cleaning and analyses. Both bi-variable and multivariable logistic regression models were fitted. Variables with p-values <0.25 in the bi-variable analysis were selected for multivariable analysis. Model fitness was checked through the use of the Hosmer-Lemeshow test. Descriptive statistics computed included mean, median, and standard deviation were presented using frequency tables, figures, and charts. CI at 95% with Adjusted Odds Ratio (AOR) was used to identify statistically associated factors for the uptake of ASM.

Ethics statement and consent to participate
All the procedures in the present study were approved by the ethics committee in research at Debre Markos University, College of Health Science (HSC/R/C/Ser/Co/56/11/13). Written informed consent was obtained from each study participant before initiating the study.
Confidentiality of the information was maintained. All methods were performed in accordance with the relevant guidelines and regulations.

Socio-demographic, economic, and service delivery-related factors
A total of 415 clients on ART participated in this study with a response rate of 98%. The median age of study participants was 39 ± 13 years. Females constituted 248(59.8%), most of the study participants 254(52.5%) were married, and 167(40.3%) of them had no formal education (Table 1).

ART knowledge and risk behaviors related factors
One hundred (24%) of the study participants had a good level of knowledge related to ART. The majority (92.5%) of study participants reported ART consists of drugs that suppress the activity of HIV. A significant number of the respondents presented a lack of understanding of technical Table 1. Socio-demographic, economic, and service delivery-related factors of uptake ASM among stable clients on antiretroviral therapy in East Gojjam Zone, Amhara, Northwest Ethiopia, 2020 (n = 415).

Variables
Characteristics Frequency N (%) terms regarding CD4 counts. Above half (53.3%) of respondents never used condoms and about one-third of participants were identified as having problems with alcohol use (Table 2).

Clinical care-related factor
In this study, the uptake of ASM was 208(50.1%) with a gender difference (19% of males and 31.1% of females). Almost half (49.6%) of the study participants had documented hemoglobin (Hgb) levels during their follow-up appointments. The majority (88%) of participants experienced a change from their baseline regimen. In this study, one in three HIV patients ever missed his/her clinical visit, the main reasons given were forgetting (37.1%), too busy (36.4%), sickness (10.7%), shortage of transport cost (7.9%), family member sickness (5%) and other conditions (2.9%). Nearly 94% of participants elected to the uptake of ASM to reduce the frequency of facility visits. Besides, 80% of study participants not uptake ASM cited personal preference as the reason (

Discussion
This study investigated the proportion of ASM uptake and associated factors among stable adult clients on ART in Ethiopia. In this study, the proportion of uptake of ASM for HIV care was 50.1% (95% CI 45, 55) with higher rates in female than male study participants. This uptake is higher than similar studies reported from 7.2% in Uganda [25], 10.3% in Zambia [26], and 28% in South Africa [27]; however, it lower than previous evidence from Guinea 59.6% [10] and 69% [12] in Malawi. This variance may reflect the difference in countries' ASM care eligibility criteria for enrolment in a model. For example, in Malawi, people living with HIV including children greater than 2 years old, adolescents, adults, and specific populations, who are well, in care for three or more months, and have suppressed viral load, are eligible for ASM of care [28]. Whereas in some countries, including Ethiopia, with low coverage of viral load testing, supply chain concerns, or other systems challenges, simpler national guidelines are offered that prescribe a combined clinical and refill visit every six months for every adult patient only [28]. Another reason for the discrepancy might be the difference in facility type, key clinical values, CD4 count, and viral load at the entry to care, as well as attributes of study settings.

PLOS ONE
Uptake of appointment spacing model of care and associated factors among stable adult HIV clients on treatment In this study, those patients who reside outside the catchment area of their ART facilities were 2.33 times more likely to uptake ASM than those who resided within the catchment area. The major reason given was that those clients outside their locality (out of the catchment area) incur both direct and indirect costs. Hence, ASM was found to save their working time and travel costs. This finding is consistent with studies conducted in Uganda, Rwanda, and Zambia [25,[29][30][31]. This may be due to travel distances to get ART service, inconvenient transportation, long facility wait times for patients and their families, and COVID-19 pandemic lockdown were possible factors impacting the uptake of ASM. Despite the distance from health care being positively associated with ASM uptake, it is recommended to avail HIV treatment services in the nearby facilities and encourage clients to use the local health facilities. The finding implied that HIV patients should be advised to attend regular follow-ups in nearby health facilities.
This study also revealed that patients whose household monthly income �5001 birr were 2.65 times more likely to uptake ASM. The probable reasons for a good level of ASM acceptance by high-income groups may be related to these patients having higher-level incomes being employed, engaged in income-generating activities, having convenient drug storage, reducing working time lost due to frequent health facility visits, and experiencing better access information from different sources. This result does not coincide with the study conducted in Kenya, Cameroon, and Namibia [32][33][34], which may reflect the country-level differences in available infrastructure.

PLOS ONE
Uptake of appointment spacing model of care and associated factors among stable adult HIV clients on treatment

PLOS ONE
Uptake of appointment spacing model of care and associated factors among stable adult HIV clients on treatment Findings from this study revealed that those patients who had strong social support were 2.21 times more likely to uptake the ASM compared to those who had poor social support. It is consistent with studies conducted in South Africa, the USA, and Sub-Saharan Africa [35][36][37]. Stronger social relationships are a rigorous protective factor against morbidity and all-cause mortality, and the supplemental guide on the ASM of HIV service delivery recommended these clients need additional support. The support can be enhanced through counseling to disclose to their family members and treatment supporters because the care and support provided by family members and communities were reported to boost self-worth that promotes positive coping.
Patients who did not have alcohol use were 2 times more likely to uptake the ASM than those who were alcohol used. This finding aligned with a study conducted in sub-Saharan Africa and East Africa [38,39]. The finding indicated that alcohol use prevention mechanisms should be strengthened and incorporated into routine HIV care.
The Virological result had an association with ASM uptake. The current study indicated that HIV patients who had <250 RNA copies/ml were 2.8 times more likely to uptake the ASM compared to their counterparts. The finding is consistent with other studies conducted in Guinea, Zambia, and other Sub-Saharan African countries [10,31,40]. Patients who have a viral load result that cannot be detected (less than 250 copies/ml of viral load) indicated a good level of both drug and clinical adherence. Therefore, clients should be encouraged to continue to take their medicine as prescribed to keep the virus undetectable. The present study revealed the ASM enrollment criteria also triggered a low level of viral load. However, the effect of ASM on Virological suppression needs further study. Months on ART were also associated with the level of ASM uptake. HIV patients with more than five years duration of ART were 2.41 times more likely to uptake ASM compared to their counterparts. This finding is consistent with previous studies conducted in Nigeria, the United States of America, and Ethiopia [16,41,42]. A possible explanation might be that patients receiving ART drugs for more than five years had adequate ART medication-related knowledge and skills, as well as were more likely to have disclosed to their family members and others in their community.
Another finding revealed that HIV patients who changed their first-line HIV drug regimen were 2.2 times more likely to uptake ASM compared to those who have not changed their baseline regimen. This finding concurred with studies done in Guinea, Malawi, and Nigeria [10,41,43]. The possible justification might be the increased pretreatment resistance to Neverapine resulted in poor treatment outcomes. Currently, the WHO recommends using other alternatives of Dolutegravir (DTG) base as a first-line regimen. Hence, most stable adult clients after changing their first-line regimen might have improved health outcomes related to improving adherence due to reducing the frequency of dosing. The majority of this study participants have changed their baseline regimen to Dolutegravir based this might be more likely to uptake ASM.

Limitation of the study
Due to the nature of the cross-sectional study, we could not establish the causal relationship between the independent and dependent variables. Additionally, the uptake of ASM was measured without considering the duration of time after at least one year on ART. This may affect the proportion of ASM uptake over time. Hence, further study is recommended to measure ASM uptake over an extended time period.

Conclusions
The proportion of the ASM for ART care uptake was low (50.1%) which was below the expected target that was 70%. Factors associated with the uptake of the ASM of antiretroviral treatment of care were socio-economical, behavioral, and clinical care-related. The association between ASM uptake and Virological suppression should be evaluated. Further, a cohort study is recommended to rule out the association between time and service uptake.
Supporting information S1 Data. Appointment spacing model of care data sets among stable clients on antiretroviral therapy in East Gojjam Zone, Amhara, Northwest Ethiopia, 2020. (SAV)